Cushing's Disease Presenting with Functional Neurological (Conversion) Disorder.

While psychiatric manifestations are common in patients with Cushing's syndrome (CS), to our knowledge, there are no reported cases of CS presenting with functional neurological disorder (FND), a neuropsychiatric condition in which patients experience neurological symptoms, such as motor dysfunctions, sensory symptoms, speech disorders, or nonepileptic seizures, in the absence of neurological disease. Here, we report a case of a complex patient with Cushing's disease who presented with multiple FND symptoms including nonepileptic seizures, bilateral lower extremity paralysis, decreased finger flexion resulting in limited hand function, and stuttering. This case illustrates a rare psychiatric manifestation of CS presenting as multiple neurological complaints. Furthermore, we elucidate how a multidisciplinary treatment approach improved our patient's FND symptoms.

Physician-Assisted Death Psychiatric Assessment: A Standardized Protocol to Conform to the California End of Life Option Act.

BACKGROUND: The California End of Life Option Act (EOLOA), which legalized physician-assisted death (PAD), became effective in 2016. The EOLOA does not require a mental health consultation in all cases nor does it state the standards for the mental health assessment. University of California, San Francisco Medical Center (UCSFMC) policy makers decided to require a mental health assessment of all patients seeking PAD under the EOLOA. OBJECTIVES: The Department of Psychiatry was tasked with developing a standard protocol for the mental health assessment of patients seeking PAD. METHODS: Members of the consultation-liaison (C-L) service developed a document to guide members in completing the mental health evaluations for patients requesting PAD. RESULTS: A committee at UCSFMC developed a clinical protocol informed by the law with an additional local expectation of an evaluation by a psychiatrist or clinical psychologist. The C-L psychiatry group at UCSF developed a standard protocol for the psychiatric assessment for use by clinicians performing these assessments. Attention to the cognitive, mood, and decisional capacity status pertinent to choosing PAD is required under the clinical guidance document. Case vignettes of 6 patients evaluated for PAD are presented. CONCLUSIONS: The local adoption of the California EOLOA by UCSFMC requires a mental health assessment of all patients requesting EOL services at UCSF. The clinical guideline for these assessments was locally developed, informed by the literature on EOL in other jurisdictions where it has already been available.

PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors.

BACKGROUND: The substantial adverse impact of miscommunication during transitions in care has highlighted the importance of teaching proper patient handoff practices. Although handoff standardization has been suggested, a universal system has been difficult to adopt, given the unique characteristics of the different fields of medicine. A form of standardization that has emerged is a discipline-specific handoff mnemonic: a memory aid that can serve to assist a provider in communicating pertinent information to the succeeding treatment team. A pilot study was conducted in which psychiatry residents were taught a mnemonic to use during their post-call patient handoffs. METHODS: The PSYCH mnemonic was introduced as a guide to help residents identify key information needed in a psychiatric emergency room handoff: Patient information/ background, S ituation leading to the hospital visit, Y our assessment, Critical information, and Hindrance to discharge. Resident post-call patient handoffs were voice recorded and transcribed for 12 weeks. The transcriptions were divided into three time periods: Time 1 (baseline resident handoff performance), Time 2 (natural progression in resident hand-off performance with experience), and Time 3 (resident handoff performance after training in use of the PSYCH mnemonic). RESULTS: There was a statistically significant decrease in the mean number of omissions after the intervention (p = 0.049). The decrease in time spent on handoffs after the intervention was not statistically significant. On the basis of a rating scale ranging from 1 (not clear) to 4 (very clear), the residents' rating of their clarity of expectations increased from a mean of 2.79 to 3.83, and their confidence rating increased from a mean of 2.57 to 3.42. CONCLUSION: The mnemonic helped decrease the residents' handoff omissions. It also helped improve their efficiency, clarity of expectation, and confidence during handoffs.

Improving residents' performance on the PRITE: is there a role for peer-assisted learning?

OBJECTIVE: The authors implemented a peer-assisted learning approach to prepare residents for the Psychiatry Resident-In-Training Examination (PRITE), with the goal of increasing test performance. METHOD: The authors developed a PRITE review curriculum utilizing a peer-assisted learning approach. The residents were randomly assigned to teams and instructed to teach assigned topic(s). The participants' PRITE scores before and after the intervention were compared with the PRITE scores of the previous residents. RESULTS: PGY-2 residents achieved the highest psychiatry percentile increase, and PGY-3 residents achieved the highest psychiatry percentile in the past 7 years. PGY-4 residents' psychiatry percentile decreased, although two residents from the previous year left for a fellowship, and the program accepted one PGY-4 transfer. All of the groups' neurology percentile increased, but were not substantially different from the previous years. CONCLUSION: Our preliminary study has shown that implementing a peer-learning strategy to prepare residents for the PRITE is feasible and may lead to promising results.

Individuals with threatening or violent criminal behavior: civil commitment or release after incarceration?

Patients who have diagnoses of a major mental illness and an antisocial personality disorder present administrative, clinical, legal, and ethical challenges. Based on an actual case, the authors discuss how clinicians could fulfill the obligation to the patient, mental health system, judicial system, and the community under these circumstances. We explore how clinical presentation of symptomatology and criminal behavior contribute to challenges in determining psychiatric care.